postanesthesia recovery miller r.d. & pardo m.c. basics of anesthesia 6th ed. ch 39,page 563-578...

Postanesthesia recovery

Miller R.D. & Pardo M.C. Basics of Anesthesia 6th ed. CH 39 ,page 563-578

報告者 :林詩烜 指導醫師 :張懷嘉

The postanesthesia care unit (PACU) is the area designated for the monitoring and care of patients who are recovering from the immediate physiologic derangements produced by anesthesia and surgery.

Admission to the postanesthesia care unit

The anesthesiologist provides the PACU nurse with pertinent details of the patient’s history,medical condition, anesthesia ,and surgery.

Praticular attention is directed to monitoring oxygenation, ventilation,and circulation.

PACU complication

Postanesthesia nausea and vomiting(1)

Factors Associated with Increased Incidence of Postoperative

Nausea and Vomiting (PONV)

Postanesthesia nausea and vomiting(2)

Prevention and treatment

（ 1 ） propofol

（ 2 ） droperidol ： 0.625-1.25mg IV

（ 3 ） dexamethasone ： 4-8mg IV with

induction of anesthesia

Upper airway obstruction

Loss of pharyngeal muscle tone Laryngospasm Airway edema

Loss of pharyngeal muscle tone(1)

The residual depressant effects of inhaled and intravenous anesthetics and the persistent effects of neuromuscular blocking drugs.

Pharyngeal muscles contract synchronously with the diaphragm to pull the tongue forward.

Breathing pattern consisting of retraction of the sternal notch and exaggerated abdominal muscle activity.

Loss of pharyngeal muscle tone(2)

Treatment opening the airway with the “jaw thrust maneuver”

or continuous positive airway pressure applied via

a facemask.placement of an oral or nasal

airway ,LMA,or may be endotracheal.

Laryngospasm

Refers to a sudden spasm of the vocal cords that completely occludes the laryngeal opening.

Treatment

jaw thrust with CPAP,if fail,immediate skeletal muscle relaxation succinylcholine (0.1-1.0mg/kg IV or 4mg/kg IM).

Airway edema(1)

Airway edema is an undergoing prolonged procedures in the prone or Trendelenburg position and in procedures with large amounts of blood loss requiring aggressive fluid resuscitation.

Surgical procedures on the tongue, pharynx, and neck, can result in upper airway obstruction because of tissue edema or hematoma, or both.

Airway edema(2)

Management ＊ An attempt can be made to decompress the air

way by releasing the clips or sutures on the wound and evacuating the hematoma.

＊ Emergency tracheal intubation is required, surgical backup for performance of an emergency tracheostomy.

Postoperative hypoxemia

Factors

leading to

postoperative

hypertension

Causes of

hypotension

in the

PACU

Factors leading to

postoperative

cardiac

dysrhythmias

Postoperative

oliguria

Delirium(1)

Preoperative risk factors include

(1) advanced age

(2) preoperative cognitive impairment

(3) decreased functional status

(4) alcohol abuse

(5) a previous history of delirium.

Delirium(2)

Postoperative

delirium

Delirium(3)

Management

＊ Early identification of patients at risk for delirium

can also guide pharmacologic therapy

postoperatively.

＊ Require restraints and additional personnel to

control their behavior and avoid self-inflicted

injury or dislodgment of intravascular catheters

and the endotracheal tube.

Body temperature and shivering (1)

The incidence of postoperative shivering may be as frequent as 65% (range 5% to 65%) after general anesthesia and 33% after epidural anesthesia.

Hypothermia (33-35℃) inhibits platelet function , coagulation factor activity, and drug metabolism.It exacerbates postoperative bleeding, prolongs neuromuscular blockade, and may delay awakening.

Body temperature and shivering (2)

Treatment ＊ Forced air warmers are used to actively warm the

hypothermic patient.

＊ meperidine(12.5 to 25 mg IV) is the most effective

treatment.

Discharge criteria

Patients must be observed until they are no longer at risk for ventilatory depression,hemodynamic, peripheral nerve function, and their mental status is clear or has returned to baseline.

謝謝大家

Questions

(o)1. 常見 PACU complication 有 PONV, 上呼吸道阻塞 , 低血壓等等 .

(0)2. 本單位用來治療預防 PONV 的藥物有 propofol , droperidol,dexamethasone.

(x)3. 本單位 PACU 使用的 discharge criteria 有意識 , 呼吸 , 活動 , 循環 ,SPO2,五項 .

(0)4. 低體溫會造成抑制血小板及凝血因子活性，加劇了術後出血 ,和藥物代謝變

慢，延長神經肌肉阻滯，可能延誤的覺醒。(0)5. Laryngospasm 是指聲帶突然痙攣導致完全阻塞喉部呼吸道 ,處理方面使用

提下顎法將呼吸道打開 ,給予持續正壓的氧氣 ,或是 lidocaine (1-1.5mg/kg IV), 如果不行 ,就要使用 muscle relaxation succinylcholine (0.1-1.0mg/kg IV or 4mg/kg IM).